Vol. 12 •Issue 10 • Page 8
Coding Corner
Interventional Radiology Case Studies
Case Study 1
Procedure: After discussion of risks vs. benefits of the procedure with the patient, informed consent was obtained. The patient was placed on the angiography table in a supine position and prepped and draped in the usual sterile fashion. To anesthetize the previously placed tract of the biliary drain, 1 percent Lidocaine was used. The patient was given xx mg of Versed and 100 mg of Demerol for conscious sedation. To attenuate the previously placed drain and remove the drain, a 0.035 Glidewire was placed.
Next a 5 French catheter was used to redirect the Glidewire into the small bowel, which was followed by a catheter. An exchange for a 0.035 Amplatz wire was made, which allowed placement of a 7 French sheath. A dilatation of the distal common bile duct was performed, which revealed a well-defined waste that was reduced. This was later followed by placement of a 9 x 18 mm wall stent across the stenosis, which was dilated to 8 mm. After recoil, the residual diameter was greater than 5 mm across the most severe portion of the stenosis. A follow-up injection with contrast through the sheath revealed adequate drainage of contrast through the stent into the small bowel. An 8 French internal/external drain was next placed across the lesion to ensure access.
Impression: 1) Angioplasty of a distal common bile duct stricture subsequently stented with a 9 x 18 mm wall stent; and 2) Placement of internal/external drain was performed to ensure access.
Code Assignments and Rationale
While not separately reimbursed by Medicare, the documentation in this report supports a separate charge for conscious sedation (99141). The material used and the monitoring provided are clearly defined. This patient already had a previously placed drainage tube in place, so a separate charge for the placement of a new tube cannot be used.
After the removal of the old tube, tract dilatation was performed. This is similar to an angioplasty and is defined by codes 74363 and 47556. Code 47556 is used because, after the dilatation, a stent was also placed. (If there had been no stent, code 47555 would have been used instead.) Placement of the internal/external drain-age tube is defined by codes 75982 and 47511.
74363 Percutaneous transhepatic dilation of biliary duct stricture with or without placement of stent, radiological supervision and interpretation (S&I)
47556 Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct stricture(s) with stent
75982 Percutaneous placement of drain-age catheter for combined internal and eternal biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, radiology S&I
47511 Introduction of percutaneous tanshepatic stent for internal and external biliary drainage
Case Study 2
Procedure: After discussing the procedure’s risks vs. benefits with the patient, informed consent was obtained. The patient was placed on the angiography table in the supine position and prepped and draped in the usual sterile fashion. Using 1 percent Lidocaine, the right groin was anesthetized.
Using a 19-gauge, thin-wall needle, an arterial puncture of the right common femoral artery followed. A 5 French sheath over a 0.035 guidewire was placed. A 5 French pigtail catheter was next advanced to the proximal abdominal aorta with a digital arteriogram of the aorta in the AP projection. The abdominal aorta appears normal with single renal arteries noted bilaterally without evidence of stenosis. Adequate visualization of the celiac and superior mesenteric artery also is noted.
A 4 French Cobra catheter was next used to select the superior mesenteric artery and to obtain a digital arteriogram of the ab-domen in the AP projection. Normal opacification of the mesenteric branches is noted. There is no evidence of a replaced right hepatic artery.
The celiac axis was next selected with a 5 French Simmons 2 catheter. Selection of the common hepatic artery was initially made and an arteriogram obtained of the right upper quadrant. Hepatic arteriogram re-veals normal opacification of the hepatic branches. There is no evidence of neovascularization or tumor blushing. Normal venous return is recognized.
We planned to perform an embolization of the hepatic metastasis, but the recent CT scan did not localize a mass. The arteriogram obtained today also failed to demonstrate a focal area of abnormality, therefore, we were reluctant to embolize the entire right lobe of the liver without a specific target. The catheter was removed and hemostasis was achieved with the use of Vasoseal device.
Impressions: A normal hepatic arteriogram was performed without evidence of tumor vascularization or neovascularization and no evidence of tumor blush. We were reluctant to embolize the liver without a target by either CT or arteriogram and discontinued the procedure. A total of 60 cc of Optiray was injected during the procedure. Medical qualifications include hypertension and history of malignancy.
Code Assignments and Rationale
As the case involves access into the arterial system, note first where the entrance into the vascular system was gained. This will determine the order(s) of selectivity that will be assigned. Good, clear documentation exists stating that the access point was the right common femoral artery (RCFA).
The appropriate catheters and guide-wires were inserted and advanced into the abdominal aorta. An injection was made and filming of this area occurred. (If only imaging had occurred, codes 75625 and 36200 would be assigned. Because additional selective studies also were performed, these codes may not be used.)
Next, the catheter was selectively placed into the superior mesenteric artery (SMA) where an injection and filming occurred. Codes 75726 and 36245 define this. The first-order code (36245) is used as this vessel arises directly off of the aorta.
Coding rules state that each vascular family should be coded separately and to the highest degree of selectivity in each family. They also state that when both a selective and nonselective catheter placement are performed (from a single vascular access point), the selective code takes precedence over the nonselective code. (This is why code 36200 is not assigned for the initial abdominal aortography injection). As the definition of code 75726 states “with or without flush aortogram,” code 75625 may not be used as it is considered inclusive of 75726.
Next, the catheter was advanced (first) into the celiac artery/trunk and then into the common hepatic artery. Because no injection was performed from the celiac artery, the selective catheterization code will be assigned based upon the placement into, and injection of, the most distal positioning or, in this case, the common hepatic artery. This is the next option/branch after bifurcation of the celiac trunk, so it increases one order of selectivity to a second order or code 36246.
As this was the first injection of this separate vascular family, supervision and interpretation (S&I) code 75726 must again be assigned to reflect the imaging. This assignment may be confirmed by closely reading the definition of code 75726: “selective or supraselective.”
75726 Angiography, visceral, selective or supraselective, (with or without flush aortogram), radiological S&I
75726 Angiography, visceral, selective or supraselective, (with or without flush aortogram), radiological S&I
36245 Selective catheter placement, arterial system; each first order abdominal, pelvic or lower extremity artery branch, within a vascular family
36246 initial second order abdominal, pelvic or lower extremity artery branch, within a vascular family
Jeff Majchrzak is vice president of radiology services and a senior health care consultant for Medical Learning Inc., St. Paul, MN.
